Medicare Part C Coverage: What Does It Cover?
Reviewed by: Ed McClane, Licensed Insurance Agent
Along with receiving Part A & B benefits, Medicare Part C often bundles your benefits with additional ones like dental, hearing, vision, and prescription drug coverage.
The two most popular choices of plans are Preferred Provider Organization (PPO)A Preferred Provider Organization (PPO) is a health insurance plan that doesn't require you to get a referral from a primary care physician to see other doctors. Most PPOs allow you to see any doctors or providers in their network. and Health Maintenance Organization (HMO).
If your provider is in-network,In-network refers to the doctors, hospitals and other providers that are inside of your provider network. A provider network is a group of providers that have agreed with your health insurance company to treat its customers. you can save money and gain additional health and wellness benefits.
You can enroll in Medicare Advantage during any of the Medicare enrollment periods. If you’re in the Initial Enrollment Period,The Initial Enrollment Period (IEP) is the seven-month period around your 65th birthday when most people are eligible for the first time to enroll in Medicare. you must have joined Part A and Part B before selecting a Medicare Advantage plan.
Are you having trouble choosing the best coverage? Let’s review the Medicare Advantage (Part C) coverage.
Find a local Medicare plan that fits your needs
Medicare Advantage (Part C) replaces Original Medicare (Part A & B), but offers the same Part A & B benefits or coverages as Original Medicare. Along with receiving Part A & B benefits, Medicare Part C often bundles your benefits with additional ones like dental, hearing, vision and prescription drug coverage.
When you have Medicare Part C, your Part C benefits ID card replaces your Medicare ‘Red, White & Blue’ card at every visit.
You can still join a Medicare Advantage plan even if you have pre-existing conditionsA pre-existing condition is an illness, injury or other medical condition you had before you enrolled in your health insurance policy..
Medicare Advantage plans are not separate from Medicare. Medicare Advantage (Part C) is private insurance required to meet all of Medicare’s regulations. You have Medicare rights and protections, even though private insurance companies manage your benefits. Medicare Advantage plans can offer additional benefits like Part D, vision, dental and hearing.
Are you eligible for cost-saving Medicare subsidies?
Medicare Advantage Plans aren’t as flexible as Original Medicare policies. Many plans only cover costs if you visit providers within their network. Health Maintenance Organization (HMO) plans generally offer narrower primary care networks, while Preferred Provider (PPO) plans are broader.
Medicare Advantage (Part C) plans vary on a state-by-state, even county-by-county basis. Let’s take a look at the two most popular choices:
Preferred Provider Organization (PPO)
- All Part C plans have a provider network, but PPO offers the flexibility to visit an out-of-networkOut-of-network refers to doctors, hospitals and other providers that do not have an agreement to treat your health insurance company's clients. Visiting an out-of-network provider typically means more out-of-pocket costs and less coverage. provider that accepts Medicare.
- In-network providers are affordable.
- You are not required to choose a primary care doctor.A Primary Care Physician is a doctor that oversees and monitors your medical care under some plan types. PCPs also may be responsible for referrals to specialists.
Health Maintenance Organization (HMO)
- You must see an in-network provider unless you need emergency care.
- Choosing a primary care doctor is a requirement.
- Plans may require a referral or prior authorization for specialists, and some tests and procedures.
- Most plans include prescription drug coverage (Part D).
Additional Part C options include:
- Special Needs Plans (SNPs)
- Medicare Medical Savings Account (MSA) plans
- Private Fee-for-Service (PFFS) plans
What extra benefits and savings do you qualify for?
Medicare Advantage plans and Original Medicare don’t cover care outside of the United States. Consider looking at a Medigap policy if you need coverage in other countries. As for traveling state-to-state, Medicare Advantage plans usually don’t cover non-emergency care if you go outside of your plan’s network.
You can have a Medicare Advantage Plan with ESRD if you meet the following criteria:
- You develop ESRD after you’ve already enrolled in a Medicare Advantage Plan
- You no longer have ESRD after treatment
- You join a Medicare Special Needs Plan (SNP) that covers ESRD
- Your Medicare Advantage Plan leaves Medicare or no longer provides coverage in your area
It’s important to note, people with ESRD were allowed to join Medicare Advantage Plans without restrictions starting in January 2021.
The short answer is no. Although Medicare Advantage plans must cover at least the Medicare “Medically-Necessary Services,” Medicare Advantage Plans can charge different deductibles, offer co-payments (for instance $30 per office visit), or various co-insurance terms (such as 20% of the procedure cost). Some Medicare Advantage plans have a limit on how much you can spend in a year.